Page 1 of 1

Request For Therapy With Raven Questionnaire

Hi! What's your full name(s)?

*

What is the contact email address?

*

What is the contact phone number?

*

How did you find me?

*

A

Psychology Today

B

Zencare

C

Instagram

D

Website

E

Word of Mouth

F

Other

Who are you currently seeking support for?

*

A

Just for me

B

For me and my partner

C

I'm not sure yet

D

Other

What is your primary reason for reaching out?

*

How long has these issues been affecting your life?

*

A

Less than 3 months

B

3-12 months

C

1-3 years

D

3+ years

E

All my life

What priority is it for you to see relief in this area?

*

A

I'd like to just check it out

B

I know something needs to change soon

C

I want to change but I just don't know if I can

D

I need support immediately

E

Other

What have you already tried?

*

Therapy

Coaching

Workshops

Books/Podcasts

Conversations with Partner

Nothing yet

What priority does therapy have in your budget right now?

*

A

Its really priority for me right now and I understand the value of the investment

B

It's important but I need to make sure its a good fit

C

I need to use my insurance to pay

D

I'm just exploring my options

E

Other

Check which days and times you would most likely want to schedule your sessions. (Check a day and a time)

*

Monday

Tuesday

Wednesday

Thursday

Friday

Weekends

Morning

Afternoon

Evenings

Check which days and times in the next 3 days are best to schedule a consultation with Raven? (Check a day and a time)

*

Monday

Tuesday

Wednesday

Thursday

Friday

Weekends

Morning

Afternoon

Evenings

Is there anything else you would like Raven to know before submitting? Based on your responses, Raven will review your submission and reach out if there's a strong fit to work together.

*